The public health burden of kidney failure in the United States is substantial, with more than 600,000 end-stage renal disease (ESRD) patients. There are two main treatments for kidney disease - dialysis or kidney transplantation. A complex, multi-tiered national system regulates kidney disease care, reimbursement, and transplantation, creating barriers to overcoming the significant racial disparities that exist in transplantation, the most effective treatment for ESRD. The federal Organ Procurement and Transplantation Network of the United Network for Organ Sharing oversees the allocation of all deceased donor organs in the US, and on Dec. 4, 2014, a major change to the allocation policy was implemented that is expected to impact racial disparities in transplantation access. We propose to study the impact of the natural experiment offered by enactment of this new kidney allocation policy on reducing disparities in the key steps of referral for transplant evaluation, wit listing, and transplantation, each of which have complexities for measurement at the local and national level. In addition, to impact disparities reduction at the service delivery level, we willuse national data to develop and then disseminate a systems-level practice of providing feedback to dialysis centers about their transplant performance to improve overall wait listing rates and decrease disparities in kidney transplantation. Our specific aims are: Specific Aim 1: To test the hypothesis that the new kidney allocation policy will lead to a reduction in disparities in transplantation at 1 year, we will prospectively examine the impact of the policy changes on racial disparities in the key steps in the transplant process post- vs. pre- allocation: a) referra from the dialysis facility for transplant evaluation in the Southeast, where we have access to this unique data, and b) wait listing and transplantation in the US. Specific Aim 2: To evaluate the impact of a systems-level approach to providing tailored transplant performance feedback and education about the kidney allocation policy, we will conduct a multicomponent, clinical effectiveness-implementation study among 750 US dialysis facilities which treat >50,000 dialysis patients. We anticipate that increasing provider knowledge will reduce disparities in transplant wait listing. The long-term impact of this application will be to influence the way organs are allocated in the US to ensure equitability through better analysis of policy and dissemination of best practices at the health systems level.